Top 10 Psoriasis Treatment Tips Steven R. Feldman, MD, PhD Professor of Dermatology, Pathology & Social Sciences Director, Psoriasis Treatment Center Wake Forest University School of Medicine Winston-Salem, North Carolina Conflicts of Interest Research, speaking and/or consulting support from Abbott, Amgen, Astellas, Centocor, Galderma, Leo Pharma, Novartis, Pfizer, Stiefel/GSK, National Biological Corporation Author of Compartments Founder of DrScore.com Chief Science Office, Causa Research 1
Approach to Psoriasis Treatment Address patients psychosocial needs Find out what patients think Enhance topical treatment efficacy Encourage compliance For generalized disease start with UVB +/- acitretin Methotrexate and biologics when needed Standard Model Psoriasis Psychosocial Joint Symptoms Ibuprofen Psoriasis Foundation Rheumatology Topicals Yes Localized? No Phototherapy Promote good adherence Methotrexate Biologics 2
#1 Address quality of life issues Ask questions & listen Touch patients & use a magnifier I imagine this may be culturally dependent Encourage patients to join a Psoriasis Foundation Bothersome Aspects of Psoriasis Appearance of the skin Scales falling off Itching* Joint pain Burning sensations Skin soreness* Hair loss How joints/bones look Time caring for psoriasis Unpleasant odors Stains on clothing or furniture Time lost from work Medication side effects Monetary cost of treatment Not able to control the psoriasis Doctors attitude to psoriasis* People reacting negatively Being avoided by people Feeling self-conscious about skin 3
#2 Use patient support groups Use the National Psoriasis Foundation Reduces isolation & ignorance Provides empowerment Patients love it & it helps you Techniques Brochures Business cards Web site (www.psoriasis.org) Please Join! #3 Topicals: Make Compliance Easier In an anonymous survey, 40% report noncompliance Involve patients in treatment planning Choice of treatment/vehicles Patients like to see efficacy now Combine slower acting agents with a superpotent topical steroid 4
Choose a Vehicle Patients Will Apply Ease of application Time it takes to apply How well it is absorbed How it feels to touch How it smells How it feels on the skin How much it stains Vehicle Preference in the Lab Less messy vehicles are often preferred Daytime & Nightime Vehicle Preference 20 15 10 5 Day Night 0 Cormax cream Cormax solution Diprolene gel Diprolene ointment Luxiq foam Psorcon E 5
Ointments aren t always more effective Can assess potency using vasoconstriction scores Modern vehicles deliver plenty of clobetasol Moisturization can help psoriasis You don t need to moisturize psoriasis Methotrexate & cyclosporine don t moisturize Deliver the steroid and the inflammation disappears Most Potent Topical Agent Ever No longer do the patients need steroids inuncted, ingested, or injected, and no more methotrexate or PUVA visits. 6
Histopathologic Effects of Skin Cap Improvement seen in just 5 hours! Baseline 2 Days 2 Weeks Forget About Zinc Randomized, double-blind, right/left study Mild to moderate, symmetric psoriasis 25 subjects applied clobetasol foam to both sides Zinc pyrithione spray to one side, vehicle to the other 7
Zinc Doesn t Add Efficacy 25 subjects applied CP foam to both sides Zn pyrithione spray to one side, placebo to other 7 6 5 4 3 2 Zinc No Zinc 1 0 Baseline 2 Weeks #4 Vitamin D Suppresses proliferation, induces differentiation Also has immune effects Slow, efficacious in 8 to 12 weeks So combine with a fast acting agent Side effects Irritation (10%) with calcipotriene, less with calcitriol Significant hypercalcemia is rare Don t use in combination with salicylic acid 8
Tip #5: Scalp psoriasis is frustrating (Because of poor compliance) Scrotum Jaw Forehead Axilla Scalp Back Palm Poor penetration Ankle Plantar foot Forearm Scalp Psoriasis: Compliance Choose the right vehicle(s) Shampoo, solution, foam, oil Use the dental floss effect See patients back in 3-5 days Use other psychological tricks so strong it stings most guys don t have what it take to use this 9
Scalp Psoriasis Treatment Misconceptions The first phase is active descaling. In case of mild scaling, regular shampooing is an option. Application of salicylic acid 5% to 10% of urea up to 40% in a wash-off ointment may enhance descaling. An automatic shampooing machine may help at day-care centers for efficient descaling. The second phase is active clearing treatment. The first-line approach is a vitamin D 3 lotion or emulsion once a day and a superpotent topical corticosteroid in a vehicle that is well accepted by the patient once a day. If this approach is not effective after eight weeks or not appreciate for reason of intolerance, a superpotent topical corticosteroid may be combined with UVB therapy. In order to optimize phototherapy of the scalp, a hair blower or a UVB fiber comb can be used. Another alternative for the second phase is dithranol and tar-based treatment at a day-care center. If all these approaches are not effective, cultures for Malassezia should be taken and a systemic antifungal treatment can be started. In case all these treatments are not effective, a systemic antipsoriatic treatment should be considered with methotrexate, fumarates, cyclosporine or acitretin. The third phase of treatment is stabilization with a vitamin D 3 analog on weekdays (once or twice daily) and a superpotent topical corticosteroid once daily during the weekend. In case a vitamin D 3 analog is not tolerated, one may restrict to intermittent applications of the corticosteroid only. The fourth phase is the maintenance phase. For this phase, a vitamin D 3 alone is the preferred treatment either once or twice daily. A tar shampoo may further support this phase. Peter van de Kerkhof, Marloes Kleinpenning and Rianne Gerritsen, In Mild-To-Moderate Psoriasis, Second Edition, copyright 2009 Feldman s Scalp Psoriasis Regimen Step 1: Clearing Get patients to apply the topical clobetasol Step 2: Maintenance Get patients to apply the topical clobetasol (as needed) Step 3: When tachyphylaxis does occur, Get patients to apply the topical clobetasol again Step 4: If patients have failed topical clobetasol, Get patients to apply the topical clobetasol 10
#6 For severe psoriasis, start safe and work up Combination treatments Hydroxyurea Cyclosporine Methotrexate Biologicals PUVA+acitretin (Re-PUVA) UVB + acitretin UVB UVB + topicals #6a Home Phototherapy 11
Adherence Over Time 7 6 Mean Weekly Use in Days 5 4 3 2 1 Acitretin Adherence UVB Weekly Use 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Time (Weeks) Tanning beds don t clear psoriasis If you put 10 patients in your light box If you see 10 patients who tried a tanning bed for their psoriasis Office UVB 80% effective Tanning Bed 80% effective You see 8 clear You see 0 clear 12
Tip #7: Acitretin is safe, effective & easy to use (when used right) Makes UVB very effective Good for psoriasis & skin cancer Monitoring is simple a lot like isotretinoin Baseline LFT s, Triglycerides Repeat in 2-4 weeks, then every 4-6 months or so Use low doses to avoid annoying side effects Don t use in women of child bearing potential No long-term cumulative side effects Explaining Acitretin Side Effects Use the NPF systemic treatment brochure Start at the top and work down Headache, depression hair loss Dry eyes, night vision Dry nose, mouth Dry skin, joint pains Don t give blood LFT s, Triglycerides Don t give to women who might get pregnant 13
Other Uses: Palmoplantar Psoriasis Our best treatment for palmoplantar psoriasis Makes thick scales fall off Dries up pustules Helps patients function New Algorithms 14
Tip #8: What If There Is Also Joint Pain? If the skin warrants systemic treatment, use it If the joints need a biologic, use it If the skin just needs UV and the joints just need a NSAID, no need to use a biologic Tip #9: Give patients the risks & benefits of methotrexate in writing MTX is very effective for psoriasis (and other inflammatory skin diseases) Risk of internal adverse reactions Treat to control the eruption, not to eliminate the eruption Monitor labs assiduously Be careful 15
Other Great Materials You can download them for free at http://www.psoriasis.org/netcommunity/page.a spx?pid=603 Tip #10: There may not be one best biologic Efficacy Safety Cost 16
Efficacy Safety Other MTX Ustekinumab TNF Inhibitors Effective, good for joints, too PASI75 30-60% Death Blood & liver toxicities Pulmonary Lymphoma Malaise Convenient Blood tests: CBC, LFTs, hepatitis panel Low cost Nausea Liver biopsy Stop alcohol Highly effective for skin, approved for joints PASI75 70-80% Theoretical risk of infection & malignancy Observed safety profile is excellent Limited experience Few injections Done in office or at home Insurance hassles High cost Effective for psoriasis, very good for joints (approved for joints, too) PASI75 50% for etanercept, 70% for adalimumab Precipitating MS Lymphoma, CHF? ANA s in 15% in RA, symptomatic is uncommon to rare More long term data but not near as much as MTX Baseline TB and hepatitis tests Self administered (2-4/week) Injection site rxn s Cost even higher with double dosing #10a: Safety Differences May Not Matter 17
#10b Biologic Adherence Assessing adherence Are you keeping the extra syringes you ve accumulated refrigerated like you are supposed to? Putting patients minds at ease Biologic? Yes, this is an all-natural antiinflammatory made in living cells that complements your body s natural healing mechanisms because I like to take a holistic approach to treating skin disease #10c Communicating Risk Information 1 in 1,000 have risk vs 999 in 1,000 don t have a problem All patients exposed to Adalimumab in 1-year period: 1,000 patients Patients presenting with serious infections: 46 /1,000 patient-years Opportunistic Infections: 0.9/1,000 patient-years Tuberculosis: 2.9/1,000 patient-years RiskCommunication Tool John Paling 2002. See www.riskcomm.com. Burmester GR et al. Ann Rheum Dis. 2009;68:1863 1869. 36 18
Use images to communicate risks in perspective Lymphoma Accidents * Lymphoma + TNFi (upper limit) TB variable screening + TNFi (upper limit) Stroke Heart Disease Cancer 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% From Least to Most: Lightning Strike MS TB TB screened + TNFi (upper limit) MVA * MS + TNFi (upper limit) Kaminska E, et al. Comparing the lifetime risks of TNF-alpha inhibitor use to common benchmarks of risk. J Dermatolog Treat. 2013 Apr;24(2):101-6. Benefits of Biologics May Outweigh Risks Systemic treatment may reduce cardiovascular risk 19
Next Steps (Lots of off label use) Combinations Any of the systemics (MTX, Etanercept, other TNF agents) with UV and/or Acitretin MTX + any biologic Cyclosporine With Acitretin With MTX Rambo treatment UV + Acitretin + MTX + Etanercept + topicals I guess you could add CyA, too Conclusions Manage patients psychosocial needs Use the NPF! Topicals work much better if patients use them Less messy corticosteroid products New natural options UVB is nearly always available Works well with acitretin MTX & biologics help those who need them 20